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The Restorative Management of the Deep Overbite

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The Restorative Management of the Deep Overbite The restorative management IN BRIEF • Discusses classification and presentation of the deep overbite. PRACTICE of the deep overbite • Discusses restorative challenges associated with the deep overbite. • Outlines treatment options for patients H. P. Beddis,*1 K. Durey,1 A. Alhilou1 and M. F. W. Y. Chan1 presenting with deep overbites. • Provides a framework for restorative treatment planning related to clinical VERIFIABLE CPD PAPER findings and details the treatment protocol at each stage. A deep overbite is where the vertical overlap of the upper and lower incisors exceeds half of the lower incisal tooth height. Problems associated with the deep overbite can include soft tissue trauma, lack of inter-occlusal space and tooth wear, all of which can present significant challenges for the restorative dentist. While management options very much depend on the nature of the situation and patient’s symptoms, options may range from provision of a simple removable appliance or splint and non-surgical periodontal therapy, to multidisciplinary care involving orthodontics, orthognathic surgery and restorative dentistry. Restorative management may involve an increase in the occlusal vertical dimension with fixed restorations or removable prostheses, and careful assessment and treatment planning is essential. This article discusses the aetiology and restorative management strategies for deep and traumatic overbites. INTRODUCTION Table 1 Classification of the traumatic overbite with associated clinical findings The majority of deep overbites are asymptomatic and where the appearance is Akerly classification Clinical presentation aesthetically acceptable patients are unlikely Class 1 The lower incisors contact the upper palatal Discomfort or indentation/ ulceration to seek treatment.1 However, this type of mucosa, away from the palatal gingival margins of the palatal mucosa incisal relationship can be problematic to Class II The lower incisors contact the palatal gingival Inflammation due to food and both the patient and the restorative dentist if margins foreign body impaction into the it results in soft tissue trauma, tooth wear or if gingival crevice of the upper incisors missing teeth require replacement. This article Class III The lower incisors contact the palatal gingival Inflammation and recession of the aims to provide an overview of the problems margins and the maxillary teeth contact the labial respective gingival margins gingival margins associated with this malocclusion and suggests options for restorative management. Class IV Wear faceting on the upper maxillary teeth and/or Loss of posterior support or a the lower labial surfaces of mandibular teeth parafunctional habit OVERBITE CLASSIFICATION The term overbite refers to the degree of in Table 1 along with associated common In situations where the incisal edges vertical overlap of the upper and lower clinical findings. It is not unusual to see occlude onto the gingival margins of the incisor teeth.2 Where the overlap is greater patients who present with a combination of opposing teeth, traumatic stripping of the than half of the lower incisor tooth height, aetiological factors and signs and symptoms. gingivae and gingival recession may result. the overbite is considered to be increased Lower incisors are particularly at risk of this or deep. This is a common finding in THE TRAUMATIC OVERBITE where there is a thin gingival biotype and individuals with Class II incisor relationships The progression from an asymptomatic deep a thin buccal plate of underlying alveolar and a Class II skeletal pattern.2 overbite to symptomatic traumatic overbite bone. Recession may also affect the palatal A traumatic overbite is where there is in an adult patient may be due to a number aspects of the upper incisors; the extent of damage to the underlying periodontium of factors.1 this depends on the level of inflammation or the hard tissues of the teeth involved. Poor plaque control associated with the present and the degree of trauma. The prevalence of the traumatic overbite palatal aspects of the upper incisor teeth Loss of posterior occluding units may has been reported to be 4.3%.3 The Akerly can cause inflammation of the palatal lead to anterior posturing of the mandible classification4 of traumatic overbite is shown gingivae and swelling. Where there is a and overclosure. This can result in soft deep overbite, this may predispose to direct tissue problems as described above, or 1Department of Restorative Dentistry, Leeds Dental soft tissue trauma from the opposing incisal tooth wear depending on the skeletal Institute, Clarendon Way, Leeds, LS2 9LU edges. The resulting discomfort can hinder and incisal relationship.6 It has also *Correspondence to: Hannah P. Beddis Email: [email protected] oral hygiene efforts, increasing the risk of been suggested that following the loss of periodontal disease. Food impaction may posterior support, the presence of a strong Refereed Paper also occur, which has been described as an lower lip may cause lingual tilting of the Accepted 19 June 2014 DOI: 10.1038/sj.bdj.2014.953 aetiological factor in the development of lower labial incisors, exacerbating the ©British Dental Journal 2014; 217: 509-515 lateral periodontal cysts.5 problem further.7 BRITISH DENTAL JOURNAL VOLUME 217 NO. 9 NOV 7 2014 509 © 2014 Macmillan Publishers Limited. All rights reserved PRACTICE a d Fig. 1a Palatal soft tissue trauma at gingival margins (Akerly Class II) with associated indentation of the tissues, discomfort and inflammation b c Figs 2a‑d 46-year-old patient with a deep overbite and left-sided scissor bite associated with a skeletal discrepancy. There was palatal soft tissue trauma and tooth surface loss associated with parafunction. The patient complained of sensitivity of the teeth and an inability to tolerate an upper partial denture Fig. 1b Periodontal therapy was carried out and a soft splint was provided to alleviate trauma In all patients, parafunctions such as habitual posturing and sleep bruxism can result in painful muscles of mastication, tooth wear and, where periodontal support has been compromised, tooth mobility and e f migration. Parafunctional habits are also likely to worsen the symptoms of soft tissue Figs 2f‑e Crowns were placed on the 11, 16, trauma associated with a traumatic overbite. 21, 24, 25 with rest seats and milled guide Where there is a loss of posterior support planes. Veneers were placed on the 41, 42, and a history of periodontal disease, this 43, 31, 32 and composite bonding to the 12, 13. A CoCr upper partial onlay denture was situation may be further exacerbated by fabricated at an increased OVD, to provide migration of the upper anterior teeth. positive occlusal contacts around the arch. Aesthetics, function and occlusal stability DELIVERY OF were restored and a lower soft night guard RESTORATIVE TREATMENT g was provided The presence of an increased or deep overbite is often a source of difficulty for the restorative clinician and the following aspects may need to be considered and addressed. Soft tissue trauma Contact between lower incisors and palatal mucosa rather than tooth-to-tooth contact between the incisor teeth may result in pain h i and swelling of the mucosa and functional difficulties (Fig. 1). are overlayed, this results in the only aesthetic pontics that do not interfere with Lack of inter-occlusal space interocclusal contact occurring between the guidance patterns (Fig. 3).8 Where there are missing teeth, a lack of lower incisors and the connector. This can Individuals with a deep overbite are often inter-incisal space means that it is impossible result in discomfort and difficulty in eating, associated with a steep glenoid fossa thus to insert a removable partial denture (RPD) or repeated fracture of the denture. constraining the lateral excursions and connector of adequate thickness without Similarly, the provision of fixed bridgework only predominately allowing elevation and increasing the occlusal vertical dimension to replace missing teeth can be challenging depression of the mandible.9 Clinically this (OVD) (Fig. 2). Unless the posterior teeth as there may be insufficient space to provide is seen in patients with Class II div 2 incisal 510 BRITISH DENTAL JOURNAL VOLUME 217 NO. 9 NOV 7 2014 © 2014 Macmillan Publishers Limited. All rights reserved PRACTICE and aesthetics. Management can be split into two broad phases: stabilisation and restorative treatment. Stabilisation Periodontal therapy A fundamental initial step in management a d of all cases is oral health education and periodontal treatment, aiming to achieve and maintain an excellent standard of oral hygiene and periodontal health. As described previously, gingival inflammation and loss of periodontal support may exacerbate symptoms and worsen compromised tooth positions. b c Splint therapy Figs 3a‑d 45-year-old patient with hypodontia (missing 22, 23 and 13), retained URC, tooth As an initial step to palliate symptoms, a surface loss affecting the URC and the lower incisors and symptoms of myofascial pain. There soft splint can be provided to protect the was an increased overbite with little inter-arch space for a connector in the 22, 23 region mucosa or teeth from further damage. This and subsequent difficulty in tolerating a removable partial denture is normally prescribed for night time wear to protect against nocturnal parafunction, however, some patients may benefit from wear at other specific times during the day. Soft splints are usually made
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